, whereby a physician committee supervised their practice: The whole of the district work of the FNS in the Kentucky mountains is done with the aid of two pairs of saddle-bags … In these bags we have everything needed for a home delivery …. In one of the pockets we carry our Medical Routines which tells us what we may—and may not—do. A very treasured possession! (pp. 1183-1184). From the outset, FNS nurses carefully maintained records of their work and their outcomes were stellar. Reflecting on her work in later years, Breckinridge (1981) noted that “trained statisticians were to come later, through a grant from the Carnegie Corporation, but from the start we had records and report sheets and kept them carefully” ( p. 166 ). When the Metropolitan Life Insurance Company analyzed the findings in 1951, they found that FNS staff members had attended 8596 births, with 6533 of those occurring in patients' homes, since 1925. More importantly, the FNS maternal mortality rate of 1.2/1000 was significantly lower than the national average of 3.4/1000 during the same period ( Varney, 2004 ). Throughout the service's existence, the FNS nurses' documentation of the outcomes of their care would serve to advance their cause. Despite exemplary clinical outcomes of the FNS, by midcentury, nurse-midwives were experiencing some of the same tensions with physicians that nurse anesthetists had faced. Changes in leadership on the advisory board, an increase in medical knowledge, the rapid development of new drugs, and a changing economic climate all played a part in accounting for these stricter controls over FNS nursing practice. The FNS medical advisory board reinforced traditional disciplinary boundaries on nursing's scope of practice ( Keeling, 2007 ). Nurse-Midwifery Education and Organization Aside from two tiny, short-lived, nurse-midwifery schools, about which little is documented (Manhattan Midwifery School in New York City and Preston Retreat Hospital in Philadelphia), the earliest school to educate nurse-midwives was the School of the Association for the Promotion and Standardization of Midwifery (APSM) in New York City ( Burst & Thompson, 2003 ). Affiliated with the Maternity Center Association (MCA), the APSM opened in 1932. More commonly known as the Lobenstine Midwifery School, in honor of Ralph Waldo Lobenstine, chairman of the MCA's medical board, the APSM graduated its first class in 1933. In 1939, the entry of Britain into World War II proved to be the catalyst for the establishment of the second major school for nurse-midwifery in the United States, the Frontier Graduate School of Midwifery (FGSM). That year, the Kentucky FNS lost many of its British nurse-midwives when they returned to England to work; in response, FNS leader Mary Breckinridge established the FGSM ( Buck, 1940 ; Cockerham & Keeling, 2012 ).
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